Clinical Data Do Not Reliably Predict Duodenal Histology at Follow-up in Celiac Disease: A 13 Center Correlative Study.

Validated nonbiopsy methods to assure duodenal mucosal healing in celiac disease are lacking, yet ongoing mucosal injury is associated with anemia, osteoporosis, and lymphoma. Most providers utilize clinical data as surrogates of mucosal status to avoid additional esophagogastroduodenoscopy. The reliability of such surrogates to predict mucosal recovery has been incompletely evaluated. The aim of this study was to rigorously assess patterns of histologic mucosal recovery at follow-up in celiac disease and to correlate findings with clinical data. Gastrointestinal pathologists from 13 centers evaluated initial and follow-up duodenal biopsies from 181 celiac disease patients. Marsh scores and intraepithelial lymphocytes (IELs)/100 enterocytes were assessed blindly. Histology at follow-up was correlated with symptoms, immunoglobulin A anti-tissue transglutaminase titers and gluten-free diet adherence. Fifty-six/181 (31%) patients had persistent villous blunting and 46/181 (25%) patients had just persistently elevated IELs at follow-up, with only 79/181 (44%) patients having complete histologic remission. IEL normalization (82/181; 45%) lagged villous recovery (125/181;69%). In a minority of patients, villous blunting was limited to proximal duodenal biopsies. No correlation was found between Marsh scores and symptoms, normalization of immunoglobulin A anti-tissue transglutaminase serology, or diet adherence. Children showed greater recovery of Marsh score ( P <0.001) and IELs ( P <0.01) than adults. Persistent mucosal injury is common in celiac disease, with discordant villous/IEL normalization. Pathologist awareness of expected findings in celiac disease follow-up biopsies, including their frequent lack of correlation with clinical data, is important for patient management, and has implications for eligibility criteria for therapeutics currently in development.

Axial slicing versus bivalving in the pathological examination of pancreatoduodenectomy specimens (APOLLO): a multicentre randomized controlled trial.

BACKGROUND: In pancreatoduodenectomy specimens, dissection method may affect the assessment of primary tumour origin (i.e. pancreatic, distal bile duct or ampullary adenocarcinoma), which is primarily determined macroscopically. This is the first study to prospectively compare the two commonly used techniques, i.e. axial slicing and bivalving. METHODS: In four centres, a randomized controlled trial was performed in specimens of patients with a suspected (pre)malignant tumour in the pancreatic head. Primary outcome measure was the level of certainty (scale 0-100) regarding tumour origin by four independent gastrointestinal pathologists based on macroscopic assessment. Secondary outcomes were inter-observer agreement and R1 rate. RESULTS: In total, 128 pancreatoduodenectomy specimens were randomized. The level of certainty in determining the primary tumour origin did not differ between axial slicing and bivalving (mean score 72 [sd 13] vs. 68 [sd 16], p = 0.21), nor did inter-observer agreement, both being moderate (kappa 0.45 vs. 0.47). In pancreatic cancer specimens, R1 rate (60% vs. 55%, p = 0.71) and the number of harvested lymph nodes (median 16 vs. 17, p = 0.58) were similar. CONCLUSION: This study demonstrated no differences in determining the tumour origin between axial slicing and bivalving. Both techniques performed similarly regarding inter-observer agreement, R1 rate, and lymph node harvest.

Fluid displacement from intraluminal thrombus of abdominal aortic aneurysm as a result of uniform compression.

Objectives The results after aneurysm repair with an endovascular aneurysm sealing (EVAS) system are dependent on the stability of the aneurysm sac and particularly the intraluminal abdominal aortic thrombus (ILT). The postprocedural ILT volume is decreased compared with preprocedural ILT volume in aortic aneurysm patients treated with EVAS. We hypothesize that ILT is not stable in all patients and pressurization of the ILT may result in displacement of fluids from the ILT, no differently than serum is displaced from whole blood when it settles. To date, the mechanism and quantification of fluid displacement from ILT are unknown. Methods The study included 21 patients who underwent elective open abdominal aortic aneurysm repair. The ILT was harvested as a routine procedure during the operation. After excision of a histologic sample of the ILT specimen in four patients, ILT volume was measured and the ILT was compressed in a dedicated compression setup designed to apply uniform compression of 200 mmHg for 5 min. After compression, the volumes of the remaining thrombus and the displaced fluid were measured. Results The median (interquartile-range) of ILT volume before compression was 60 (66) mL, and a median of 5.7 (8.4) mL of fluid was displaced from the ILT after compression, resulting in a median thrombus volume decrease of 11% (10%). Fluid components can be up to 31% of the entire ILT volume. Histologic examination of four ILT specimens showed a reduction of the medial layer of the ILT after compression, which was the result of compression of fluid-containing canaliculi. Conclusions Applying pressure of 200 mmHg to abdominal aortic aneurysm ILT resulted in the displacement of fluid, with a large variation among patients. Fluid displacement may result in decrease of ILT volume during and after EVAS, which might have implications on pre-EVAS volume planning and on stability of the endobags during follow-up which may lead to migration, endoleak or both.

[A woman with a persisting ulcer on the chin]. / Een vrouw met een persisterend ulcus op de kin.

A 62-year-old woman presented with an ulcerative lesion on the chin. She had not visited tropical regions, but she had been in Cyprus. A skin biopsy revealed coccoid micro-organisms resembling Leishmania. Subsequently a PCR was performed which showed Leishmania donovani and Leishmania infantum complex and the diagnose 'cutaneous leishmaniasis' was confirmed.